Programme director
Dr Norman Mabasa, Chairperson of the Board of SAMA
Professor Ed Coetzee, the President of SAMA
Members of the Board of SAMA
Representatives of various health sector stakeholders
Distinguished guests
Ladies and gentlemen
Colleagues
It was with great humbleness and pleasure that I accepted to make a keynote address to a distinguished gathering of this nature and significance. When I looked at the conference programme, I found the theme and topics of the SAMA 2010 conference to be very appropriate for the exciting times that our cherished health system is undergoing. In fact, I thought topics best suited the theme “Our health system: where to next?” I will elaborate why I say this.
For almost two decades now, our health system has been limping along on what I would call cockeye limbs, in that we have over the years carried on with a health system that is so imbalanced and inherently iniquitous. We have continued with business as usual even when with the passage of time, we have increasingly gathered evidence that clearly indicates that our people are not well, that our health services provision and delivery mechanisms are not working and that many of our deaths are actually avoidable.
Despite having the state of art health facilities, internationally acclaimed health systems researchers and financial and human resources that many other countries can only dream of, our life expectancy rate has declined steadily over the years, our infant and child mortality rates are in many instances comparable to those in countries that have just emerged from prolonged civil strife. In fact, the special edition of The Lancet in 2009 proclaimed that South Africa is among the 12 countries in the world that has experienced a further deterioration of its infant and child mortality statistics and is among the group of countries that are least likely to achieve any of the health-related Millennium Development Goal targets. This is despite being classified as an upper-middle income country with a reasonable level of economic growth.
Many of us sitting in this room today have spoken about or have heard about the dichotomy that so well characterises our health system in many different conferences – a better performing and resourced private sector that serves a minority of our people coupled to a generally strained public sector that is faced with a population that carries a significant burden of the nation’s disease profile.
During the entire period when all these adverse aspects of our population were worsening, we instead stood on separate sides of the fence and pointed fingers at each other while the performance of our health system deteriorated and consequently many of our people died unnecessarily.
Ladies and gentlemen, this conference for me provides an opportunity for all of us, public and private, to seriously evaluate where we are in terms of realising the Constitutional provision of truly realising the right to health of every South African, irrespective of their socio-economic status and devoid of the many injustices that we learn of daily through the media and other sources of information. It is an undeniable fact that our health system is bedevilled by a number of challenges; more so in the public than in the private sector, but many of these challenges can be easily addressed through collaborative engagement and better resource sharing between the two sectors.
This is why I have deliberately chosen not to reiterate the challenges but rather to speak about the steps we have already initiated towards promoting better and more effective health system leadership and governance, and the enhanced collaboration with and involvement of all key stakeholders in our priority health sector programmes. We must now bury the fragmented and disjointed legacy of the health sector and instead focus on building a well coordinated, institutionally sound and sustainable health system that we can all proudly call our health system.
This change has already begun. The Department of Health’s National Strategic Plan for the period 2009to 2014 clearly lists the 10 point plan as the core set of areas that the department, both nationally and provincially, has already started focusing on in terms of ensuring that we indeed realise the goal of “A long and healthy life for all South Africans”.
Within this 10 Point Plan we are focusing on a core set of areas: enhanced overall stewardship and the strategic direction that our national health system must take; changing of the mechanisms that we use to finance our health services provision and delivery platforms.
Government has gone a step further by taking practical measures to ensure that by 2014 the Department of Health would have contributed positively to improving the status of all South Africans. In its programme of action, health and education are given particular importance. The priority for the health sector, as I have referred to previously, is to contribute to government’s vision of “A long and healthy life for all South Africans”. To accomplish this vision government has identified four strategic outputs which the health sector must achieve. These are – 1) Increasing life expectancy; 2) Decreasing maternal and child mortality; 3) Combating HIV and AIDS and decreasing the burden of diseases from Tuberculosis and other communicable diseases; and 4) Strengthening health system effectiveness.
Taking a step backwards to fully interrogate and understand why things have continued to happen as they have over the years despite the many failings, we as the Department of Health have initiated a process of self-introspection and self-reflection. This decision was based on the fact that in addition to lack of financial resources, many of our challenges are also as a result of a mixture of systemic and process failures within the health sector which all ultimately translate into either poor health services delivery or poor accessibility and quality of the services we offer.
This process of introspection and reflection has aptly led us to the conclusion that in order to ensure that the Department of Health provides effective strategic leadership and stewardship over the national health system, especially the building blocks of effective health services delivery. These building blocks include quality improvement programmes for our public health system, a well capacitated health workforce, strong and reliable health information and management systems, and an appropriately structured and sustainable health system financing mechanism.We are getting these basics right. We are ensuring that our house is in order to ensure coherence, coordination and effective health services provision that is responsive to the needs of our people, contributes to social and financial risk protection, entrenches efficient use of available resources and improves the health status of the national population. These are the principles and underlying goals upon which all our efforts are founded.
A strong component of the health sector negotiated service delivery agreement is the need to consider the health sector as a dynamic system that consists of building blocks which on their own cannot translate into the realisation of the objectives that we set for ourselves. The implication of this is the need to direct sustainable efforts towards building multiple partnerships with stakeholders like SAMA to ensure that the public and private sectors interact to ensure the achievement of the purpose for which they were designed: a long and healthy life for all South Africans.
The implementation of the national health insurance is imminent and 2012 is the date of commencement of the roll-out. Among the many priorities listed in the strategies intended to yield better health system performance, the national health insurance poses a strategic initiative on the part of the Department of Health to harness the financial and human resources in the health sector and gear these resources towards improving the quality of life of our people. The national health insurance policy development processes have reached an advanced stage and following the lull that had followed the initial discussions around the announcement to move towards national health insurance, the topic is now back on everyone’s agenda. The next phase of work around this matter is to finalise the policy document and process it through Cabinet the consultation and policy revision processes will follow due processes and procedures as stipulated by government for such a far-reaching policy document.
Together we must do more to improve the performance of the health system in the interim as well as in the long run. We need to learn from the pockets of excellence within the current fragmented health system and capture these lessons to expeditiously create a health system that is first-rate in a sustainable manner, with minimal deficiencies that are proactively addressed by functional, integrated and strong institutional and organisational elements at both the national and sub-national levels, including the involvement of key stakeholders within in particular the health workforce.
The current public health system and the delivery of Health services in South Africa have not been without challenges and core to these is the significant loss of health professionals which has negatively affected the delivery of quality health services. In recent years the public health service has experienced an exodus of health professional to developed countries or within the country moving from rural to “urban” areas including movements from public to the private health sector.
The health professionals referred to in this case are highly skilled professionals from various categories particularly the medical and nursing professions. It is important to note that these challenges are not unique to South Africa as they are also experienced in most developing countries. It is also disheartening that some newly qualified professionals are also aspiring to migrate, thus further diminishing the hope of having an adequately, skilled and appropriately resourced public service in the near future.
The reasons for the migration of Health professionals have been widely documented by governments all over the world and through independent research studies. In most cases migration has been attributed to two main factors namely; poor remuneration and/ unattractive financial incentives and non financial factors such as poor working environment. Other studies have added low morale of health professionals as another factor contributing to the increased level of migration.
The Intra-health International study on retention of health care workers focusing on challenges and responses identifies three main factors that contribute to Health Worker shortages which are namely:
- decreasing student enrollment in health training institutions
- delays or moratoriums in the hiring of qualified professionals
- high turn-over among those already employed.
However in most cases, poor financial compensation and unsatisfactory working conditions are emerging as the most likely “push factors” causing workers to move between sectors or across borders.
Whilst most studies have shown that financial compensation alone does not explain migration decisions – high turn-over is often influenced by dissatisfaction with one or more attributes of the work environment which includes inadequate resources (equipment and supplies), weak performance management, leadership and supervision structures (among these factors includes, lack of recognition for work done; stress due to heavy workload and so forth).
Having identified the problem and the cause it then becomes imperative for government to develop strategies for retention of health professionals and to also look at other initiatives and approaches that have been adopted by other countries that experienced similar challenges taking into consideration our context.
In order to intervene beyond a country’s level, various international and regional agreements as well as discussions aimed at addressing retention and migration of critical staff in the health sector have been concluded through various forums including the following:
- First Global forum, on Human resources for health, 2008; AU Health Minister’s decisions on HR, 2005; (NEPAD, 2001). The Fifty-ninth World Health Assembly held during May 2006 also highlighted the need for the revitalisation and strengthening of training institutions and rapidly increasing their health workforce
- Most recently, the Sixty-Third World Health Assembly held in May 2010 directed the Director–General to, among other things; give all possible support to member states, as and when requested, for the implementation of the WHO Global Code of Practice on International Recruitment of Health Personnel
- The Southern African Development Community Human Resources for Health Strategic Plan (SADC – HRH) (2006 to 2019) which requires governments to conduct situational analysis and provide report on the magnitude and impact of the “brain drain”.
With particular reference to South Africa, various approaches and or measures have been designed/taken in order to minimise migration of health professionals focusing on both financial and non-financial incentives including the following:
- Agreement between South Africa (SA) and UK wherein SA professionals work in UK National Health Service and UK staff serves in rural parts of South Africa (Braine, 2005)
- In addressing financial incentives, the department introduced a “rural and scarce skill” allowance in 2003 – to curtail the number of health workers opting to work in other countries
- Implementation of the remuneration Policy for Health Professional employed in the Public Sector – the Occupational Specific Remuneration and Career Progression Dispensation (OSD).
Finally retention strategies should not only seek to address financial incentives but also to enhance a conducive work environment. Combination of the two is more likely to boost job satisfaction including supportive supervision and opportunities for career advancement and opportunities for training.
The Department of Health will continue to work with all stakeholders including you to ensure that the health services respond appropriately to the needs of our communities
Wishing you a productive meeting.
Thank you very much.
